Reservation Form

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

If you cannot enter number, put in comments at end of form.

Email*

Enter Email Confirm Email

2nd Email (in case the first doesn't work)

Enter Email Confirm Email

Do you have a passport? (6 months on passport required for entry into Ecuador)*

Yes
No

Age*

Gender*

Male
Female

Are you a University of Metaphysical Sciences student? (5% discount for UMS students)*

Yes
No

Where did you hear about Gaia Sagrada?*

Which length of retreat are you planning to attend?*

5 Days
7 Days
12 Days

Arrival Date*

If you stay a few days before or after the retreat, here are the prices for non-retreat nights at Gaia Sagrada https://gs.nfshost.com/reservations-booking/room-and-apartment-rental-prices-at-gaia-sagrada/

Departure Date*

What is your preferred housing option?*

Dormitory
Shared Room (Bunk Bed)
Shared Room (Double Bed)
Private Room
One Bedroom Apartment

What is your second choice?*

Dormitory
Shared Room (Bunk Bed)
Shared Room (Double Bed)
Private Room
One Bedroom Apartment

Do you snore?*

Yes
No

Would you like to make a down payment or pay in full now? (If your arrival date is less than 30 days from today, payment in full is due now)*

50% down payment
Pay in full now

Would you like to rent a security box for $1 per day? (Not needed if you are in private room or apartment. Bring your own padlock, mid sized.)*

Yes
No

Would you like to rent a heater during your stay? PRIVATE AND SHARED ROOMS ONLY ($25 for 12 days, $2.25 per day) Apartments come with gas heater, dorms do not have heaters. Heaters are not really necessary, but it gets chilly at night if you plan to spend time in your room and not with the group at the campfire or community center with the woodstove where the wifi is.*

Yes
No
Undecided

Laundry $5*

Yes
No
Will decide later

Do you want to pay for a load of laundry? Some people find that they need to do laundry at some point during the retreat. Your clothes are washed, dried and folded for you.

Karma Yoga*

Yes, I agree to do some karma yoga in community spirit (1 hour per day).
No, I just want to relax. Can I pay an extra $10 per day so i don't have to do anything?

I understand that if I am staying for more than 2 nights I am expected to chip in an hour per day (or pay $10/day extra if I don't do Karma Yoga) to help keep things clean and orderly. I will chip in when I see something that needs to be done, like weeding in the gardens, sweeping a floor, dishes in the kitchen, plants needing water, bringing in firewood, etc. This helps Gaia Sagrada keep the prices low! I understand that there is no heavy lifting expected of me. Thank you for giving me a chance to save money this way!

Optional Shamanic Cleansing, $35 (Personal session with the shaman)*

Yes, schedule me for a shamanic cleansing at the beginning of the retreat.
No
Undecided

This is optional so that people on a budget can have a slightly lower price for the retreat. The shamanic cleansing is really wonderful, everyone raves about them, so you might want to treat yourself to this! The shaman does a personal session with you for 30-45 minutes to help you clear your energy, address physical issues you might have, and get ready for the ceremonies that follow in the retreat. They are offered before the first ceremony of the retreat.

Total Price for Housing, Retreat and Extras (include retreat fees, extra nights, food, + extra costs listed below)*

Transportation to Gaia Sagrada $35 (required) / Extra Nights https://gs.nfshost.com/reservations-booking/room-and-apartment-rental-prices-at-gaia-sagrada / Shamanic cleansing $35 (optional) / No Karma Yoga, just relax $120 (optional) / Security Box $12 (optional) / Laundry $5 (optional)/Heater

Do you have special dietary or medical needs and conditions we should know about? (ie: Epilepsy, diabetes, etc.)*

Yes
No

If you have special dietary or medical needs and conditions we should know about, please explain:*

What has attracted you to come stay at Gaia Sagrada?*

Is there anything you would like to share about yourself, who you are, what you do, what your skills are? We would love to know a little about you if you care to share.*

Emergency Contacts (required for Shamanic Retreat participants)

For each emergency contact, please include name and relationship to you, address, phone number, and email address. We will not contact either person unless there is an emergency and we will not put either one on an email list. We respect privacy rights.

Emergency Contact #1 Name*

First Last

Emergency Contact #1 - Relation to you

(father, mother, brother, sister, friend, etc.)

Emergency Contact #1 Phone*

Emergency Contact #1 Email*

Enter Email Confirm Email

Emergency Contact #1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact #2 Name*

First Last

Emergency Contact #2 - Relation to you

(father, mother, brother, sister, friend, etc.)

Emergency Contact #2 Phone*

Emergency Contact #2 Email*

Enter Email Confirm Email

Emergency Contact #2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would you like to be on our email list to be alerted of specials, events, and our quarterly newsletter?*

Yes
No

This email list is connected to University of Metaphysical Sciences. (We don't send emails out very often, so we promise you won't be bombarded. Also, we never share our lists with anyone else, so you will only get emails from us)

Shamanic Ceremony Questionnaire

Your answers to these questions are given to the shamans. Tell the shamans what you hope to heal, gain, or experience in these ceremonies!

Have you ever attended a shamanic plant medicine ceremony before? If this is your first, that is fine, just mention that here. If you have experienced peak consciousness in non-ceremonial settings, that is fine too. Please explain.*

What do you hope to gain from your experience with Sacred Ceremony at Gaia Sagrada? What are your goals?*

What medicines are you taking? Please be specific. Include herbal formulas and vitamins.*

Have you ever been or are currently taking anti-depressants? Are you taking SSRIs, SNRIs or MAOIs? If yes, which ones and why?*

Do you have any disease or disability? If yes, please describe*

Are you vaccinated or unvaccinated for Covid 19?*

(It's important we know for health reasons)

Yes
No

How do you feel about vaccination? Are you ok with the fact that both vaccinated and unvaccinated people will be at the Gaia retreats?

Do you have any respiratory conditions, heart issues, high blood pressure or diabetes? If yes, please explain. YOU MUST CONTINUE YOUR MEDICATION BEFORE AND DURING RETREAT IF YOU HAVE ANY OF THESE CONDITIONS!*

Do you have psychological conditions or diagnosis? If yes, please describe condition and treatment.*

Do you practice any kind of spiritual practice? If yes, please explain.*

Agreements

HEALTH & MEDICAL AGREEMENT*

Yes
No

I understand that Gaia Sagrada cannot provide me with medical attention nor does Gaia Sagrada have a doctor or nurse on site. I understand that the hospital is approximately an hour away. I am alerting Gaia Sagrada in the "special dietary or medical needs" section if I have health conditions which staff needs to know about for my safety. By submitting my reservation for a Shamanic Ceremony Retreat at Gaia Sagrada, or any other type of stay at Gaia Sagrada, I understand that my health and well-being is my responsibility and not that of Gaia Sagrada, staff, or associates thereof. I am bringing medicines I need with me, I have consulted with my doctor if I feel the need, and I have enough money to take care of my own health needs. If I have signed up for the shamanic retreat, or choose to when I am there, I take full responsibility for my experiences or reactions to the Sacred Ceremonies. I choose to participate in Sacred Ceremonies, or simply stay at Gaia Sagrada without being a participant in the retreats, of my own free will. If participating in the shamanic ceremonies, I know that I will be partaking in plant medicine teas. Whatever type of stay at Gaia Sagrada I choose, I promise to be careful, follow directions, and ask for help if I should need assistance in any way whatsoever.

LEGAL RESPONSIBILITY & REFUND AGREEMENT*

Yes
No

By submitting this reservation, I do not hold Gaia Sagrada, University of Metaphysical Sciences, Wisdom of the Heart Church, nor any employee thereof responsible for my belongings, health issues, or any other unforeseen circumstances. I have read and agree to the cancellation/refund policies (https://gs.nfshost.com/reservations-gaia-sagrada-spiritual-retreat/refund-policy/) and understand that all events, classes, workshops, and retreats are for entertainment and relaxation purposes only, not therapeutic in nature.

Comments

Please comment on anything not covered by the questions on this form. For example, let us know if you have special needs, or remind us of arrangements you made through previous emails or phone calls, or include anything else you would like to share!